hormone havoc: terri%suresh%aprn,%msn,%dnps

9/5/15

Copyright © Terri J. Suresh 2015 1

!Hormone Havoc:!

Dispelling the Myths!

Terri Suresh APRN, MSN, DNPs

Founder, Prac--oner Hormonal Health, Wellness, & Aesthe-c Centers

Prac&cing in a variety of specialty se3ngs since 1996 Special Interest in Menopause and Andropause

Todays Inten&on •  Broad overview and concepts of HRT:

– Hormone types and ac7on in body •  Estrogen, progesterone, testosterone and thyroid

– Different type of HRT replacement op7ons and their differences

– Op7mal serum ranges for balance – Medical studies suppor7ng HRT –  Key nutrients that work in tandem with hormones in the body

–  This is not a “how to” workshop as that would take days to teach

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What is difference between trea@ng and healing?

•  When you treat the context remains the same

•  When you heal the clinical response is elicited by a change of context so as to bring about an absolute removal of the cause of the condi7on

Hormone Replacement Therapy Root Cause vs. Band-‐aide

•  Injured 7ssue HEALS with nutrients not drugs •  Natural cell membrane receptors for hormones evolved with

natural hormones and cannot adapt to synthe7c hormones –  Lock & Key –  The human body has receptors for natural hormones, there are no

receptors that exist for synthe7c hormones –  Natural Hormones have been shown to not only restore and promote

op7mal health, but heal many chronic illness and Disease states:

•  Drugs TREAT symptoms of menopause and andropause

Hormones From the Greek word “I arouse to ac7vity” First used in the Lancet 1905 William B. Hardy (1864–1934)

Vital to EVERY cell in our

body!

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Why Does Menopause MaKer?

•  100 years ago menopause was the end of lifespan

•  50 years ago women lived 20 years a_er menopause

•  Now the post-‐menopause life has increased by 30+ years

•  How do we op7mize those 30+ years??

How do you (or your pa7ents) FEEL? The Tangibles

Sounding Familiar??!

The answer?

Anxiety, depression, nervousness, sleeplessness, inability to focus, & irritability are NOT Prozac, Xanax,

Ambien, or Concerta deficiency states!

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Just for fun…… Cholesterol

Pregnenolone Progesterone

17a-Hydroxypregnenolone 17a-Hydroxyprogesterone

DHEA Androstenediol

Androstenedione Testosterone 17a-Hydroxydehydro-

epiandrosterone

Estrone

Estradiol

Estriol

Dihydrotestosterone (DHT)

16a-Hydroxy- androstenedione

16a, 19-Dihdroxy- androstenedione

16a-Hydroxyestrone (bad guy)

!  Estrogen has 400 functions in the body! !  Control hot flashes !  Maintain bone density !  Helps maintain memory !  Reduces risk of colon cancer !  Maintains collagen in your skin !  Increases serotonin and dopamine (the happy

hormones!) !  What's Optimal?

!  FSH suppression !  Symptom relief!

!  Smoking and Stress decrease estrogen!

Estrogen The Mortality Toll of Estrogen

Avoidance-‐ Yale Study

Analysis of the 2011 WHI-‐ET (Women’s Health Ini7a7ve Estrogen-‐Alone Trial) data, showing that a minimum of 18,600 and as many as 91,600 excess deaths occurred between 2002 and 2011 among hysterectomized women aged 50-‐59 years due to ET avoidance

Am. J. Public Health 2013

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•  Progesterone receptors are found in the uterus, CNS, mammary glands, and pituitary.

•  Natural progesterone can be delivered via many different routes: oral, transdermal, sublingual, intravaginal, intramuscular, intrauterine, and rectal.

•  Microniza7on of progesterone increases the available surface area of the drug and enhances its intes7nal absorp7on.

•  Oral micronized natural progesterone is available in the United States as Prometrium (now generic but 30% efficacy difference!)

•  Natural progesterone creams vary greatly in potency. •  A MUST in women with a uterus on estradiol replacement •  Side effects historically decrease compliance.

Progesterone Progesterone •  Progesterone is universally deficient in postmenopausal women and is uniformly replaced unless precluded by side effects.

•  Replacement dose is accomplished by 7tra7ng the deficient steroid to levels present in menopausal women (>10 recommended).

Hargrove JT, Osteen KG. An alternative method of hormone replacement therapy using the natural sex steroids. Infert

Repro Med Clin N Am. 1995;6:653-674.

• Micronized progesterone (prometrium) or compounded 50-‐300 mg / day: NO GENERIC! • Start at 100 mg typical dose

Estrogen has over 400 functions in the body…

BUT did you know testosterone is THE hormone!

•  Thousands of receptors in the temporal

and parietal lobes our brain •  Provides major symptom relief for men

and women. •  Protects the BONES, BRAIN, BREASTS,

HEART, JOINTS, and Relationships!!!

MEN •  Improved erec7le ability

•  Prostate protec7on •  Cardiovascular protec7on

•  Lower cholesterol, Increase HDL

•  Increased energy •  Feeling of overall well-‐being

Positive Effects of Bio-identical Testosterone

! Reducing body fat ! Builds Muscle Mass ! Reduced anxiety and irritability

! Cogni7ve clarity

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WOMEN •  Heart Protection •  Lower cholesterol and LDL •  Increased energy •  Enhanced sleep •  Feeling of overall well-being •  Reducing body fat •  Stronger bones and muscles •  Depression relief •  Reduced “brain fog” •  Enhanced libido

Positive Effects of Bio-identical Testosterone Sherwin Study

•  Prospec7ve , double blind, cross over study •  Physical and Psychological Symptoms

•  Estrogen-‐androgen •  Estrogen alone •  Testosterone alone •  Placebo

Testosterone was superior for relief of energy, well being, soma7c complaints, and psychological symptoms Worst was estrogen alone and placebo

1985 A.J.O.G.

Men with Low T

Men age 30-‐70 will lose 1-‐ 3% of total testosterone produc@on per annum: •  Increased Risk for Alzheimer's Disease •  Increased Risk form CVD •  Increased Risk for ORF •  Increased Risk for Prostate Cancer •  Increased Risk for DM •  Increased Risk for Sarcopenia

What's OPTIMAL?

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Women with Low T

Women age 20-‐40 lose 50% of their testosterone produc@on: •  Increased risk for Alzheimer's Disease •  Increased Risk form CVD •  Increased Risk for ORF •  Increased Risk for DM •  Possibly Breast Cancer

What's OPTIMAL?

Total Testosterone – Women

•  <14-‐80 – expected range> •  70 or above – normal •  60-‐70 probably asymptoma7c •  50-‐60 some loss of energy •  40-‐50 greater loss of energy, some loss of mental clarity, mild decrease in: libido, muscle loss, weight gain

•  30-‐40 all of the above but worse •  <30 everything is at its worst

“Physiologic” HRT: What’s the best?

•  Need Bio-‐iden7cal Hormones •  Biologically available-‐ not in Depo form •  Absorbed directly, not taken orally or transdermal

•  Biologically Effec7ve – reproduces steady, consistent serum levels

•  GOALS: OPTIMIZE (not “normal lab”) and balance in men and women

Lets review our options!

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Oral HRT Conven7onal HRT Hormone replacement therapy

Women's Health Ini7a7ve Trial 2002… A flawed study?

Poten7al and Unnecessary Effects of Oral Estrogen Therapy

!  Breast tenderness !  Increased risk of endometrial cancer and breast cancer !  Increase the risk of heart disease !  Increase risk of Alzheimer’s Demen7a !  Weight gain !  Vaginal bleeding !  Headaches !  Nausea and vomi7ng !  Fluid reten7on !  Blood clots !  Leg cramps !  Gallstones

Why? •  First pass metabolism •  High doses •  No individualized dosing •  No BALANCE with other

androgens!

Patches

!  Estradiol levels better than pills, !  no first pass = less side effects

!  Adhesive problem

!  Need to be changed throughout the week !  Some weight gain, but less fluid retention

than being on synthetic or horse estrogen !  NO testosterone included!

!  45% of people do not absorb hormone through the skin!

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Creams/Gels

!  Did you apply enough? !  Have to remember to rub it in daily !  Short half-‐life; may need twice daily dosing !  Applied topically onto the skin (is it even absorbing?)

-‐How long do I have to wait to get dressed? !  Can transfer to others (babies and pets) !  No dosing parameters: guesswork !  Most important estriol (as in the product BiEst) does not

have bone, heart, and brain protec@on that pellets offer, proven in studies!

TESTIM 1%

What is optimal again??

Injectable Testosterone

!  Uneven absorp7on !  Significant “roller coaster” effect !  99% synthe7c hormone !  Significant adverse effects:

!  Liver toxicity, heart disease, !  Prostate Cancer !  Elevate LDL, VLDL, decrease HDL cholesterols !  Higher rate of aroma7za7on ( i.e. higher E2 levels) !  Higher erythrocytosis = increase blood clot risk

!  Anabolic steroids (17-‐α-‐alkyl) cannot be aroma7zed and therefore are very dangerous. Many studies prove this.

!  ALWAYS Wears off before 7me for next shot…makes guys really cranky….

Synthe&c Testosterone Increases Platelet Thromboxane A2 Receptors and Platelet Aggrega&on

•  Testosterone Cypionate vs Saline •  TXA2 is a metabolite of platelets •  Two significant ac7vi7es

–  Increase platelet aggrega7on –  Constricts vascular smooth muscle

•  Inhibi7on of TXA2 by aspirin decreases thrombo7c cardiovascular events

Ajayi A. Circulation 1995;91:2742

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Subcutaneous Hormone Pellets

!  Natural, non synthe7c, yam or soy derived compounds

!  Same molecular structure as human hormones !  Lasts longer than other treatments 4-‐6 months !  Are the most widely studied form of natural hormone therapy

!  Provides a steady stream of hormone in your blood – no roller coaster effect

!  Individualized dosing !  Placed under the skin, don’t even know its there!

History of Pellets !  Developed in 1939 for women who had radical

hysterectomies !  Salmon, U., et al. Use of estradiol subcutaneous pellets

in humans. Science 1939, 90: 162.

!  Discussed the use of estradiol and testosterone pellets for the symptoms of menopause !  Greenblax, R. (1949). American Journal of OB/GYN 57,

244-‐301.

!  Widely used in Europe and Australia

What's happening on the inside? The Intangibles…

MY PCP SAYS THERE IS NO EVIDENCE……its “voodoo” medicine….its investigational…

I would suggest it is evidence based…You decide!

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HRT & The Breasts

Androgens and the Breast

•  Predominant data from in vitro studies have shown that androgens actually have apopto7c and an7-‐prolifera7ve effects and not s7mulatory effects

•  Animal models have shown similar results finding that androgens inhibit breast cancer growth

Menopause International 2008; 14: 117–122.


•  Hyper-‐androgenism in pa7ents with polycys7c ovarian syndrome with elevated levels of endogenous T is not associated with an increased risk of breast cancer and may, in fact, be protec7ve

•  High-‐dose androgen therapy also has been effec7ve in trea7ng pa7ents with advanced breast cancer

Menopause International 2008; 14: 117–122.


•  Clinical and non human primate studies suggest androgens inhibit mammary epithelial prolifera7on and breast growth

•  Addi7onally, estrogen par7cularly in oral form, s7mulate SHBG and reduces free testosterone

Dimitrakakis and Bondy. Breast Cancer Research 2009; 11:212

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Nurses Health Study

Colditz NEJM 1995

!  121,700 nurses

!  Conjugated Estrogens increase risk of breast cancer

!  Estrogen plus Testosterone no increase risk of breast cancer

Estradiol and Progesterone Regulate the Prolifera7on of Human Breast Epithelial Cells

•  Adding progesterone reduced the E2 induced epithelial cell prolifera7on

• Mitoses were less in the E2 and P group

Fertility and Sterility 2008;69:963-970

Hormone Replacement Therapy AQer a Diagnosis of Breast Cancer in Rela&on to Recurrence and

Mortality •  2755 women age 35-‐74 •  The rate of breast cancer recurrence was 17 per 1000 person-‐

years in women who used HRT •  30 per 1000 person-‐years in nonusers •  Breast cancer mortality rates were five per 1000 person-‐

years in HRT users and 15 per 1000 person-‐years in nonusers •  Total mortality rates were 16 per 1000 person-‐years in HRT

users and 30 per 1000 person-‐years in nonusers

Journal of the National Cancer Institute, Vol. 93, No. 10, May 16, 2001

Breast Cancer Incidence with Pellets 1992-‐2002

Time on Number of Cases of Pellet HRT Pa7ents Total Breast Cancer

0-‐2 years 352 1

3-‐5 years 471 0 5-‐25 years 153 0

976 1

Tutera 2003

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Terri Suresh APRN, MSN , DNPs 2009-‐2014

•  15,000 Inser7ons •  20% males •  80% females •  Total Females= 12,000

inser7ons •  Avg Frequency 3.6 months •  3333 female pa7ents •  3 breast cancers, no

mortality, 2 on estradiol

•  41,000 insertions •  20% males •  80% females •  Total Females= 32,800

insertions •  Avg Frequency 3.6

months •  9,111 female patients •  Total 9 breast cancers, no

mortality

Dr. Gary Donovitz 2008-‐2014

Rapid response of breast cancer WITH intramammary testosterone-‐anastrozole IMPLANT

•  2.4-‐cm tumor in the le_ breast •  Three combina7on implants each containing 60 mg of

testosterone and 4 mg of Anastrozole were placed anterior, superior, and inferior to tumor

•  Three addi7onal testosterone-‐anastrozole implants were again placed peritumorally 48 days later

•  By day 46, there was a 7-‐fold reduc7on in tumor volume, as measured on ultrasound

•  By week 13, they documented a 12-‐fold reduc7on in tumor volume

•  Therapeu7c systemic levels of testosterone were achieved without eleva7on of estradiol

Glaser R. Menopause: The Journal of The North American Menopause Society Vol. 21, No. 6, p

!  Testosterone delivered by pellet implants does not increase risk of breast cancer unlike oral, synthe7c methyl-‐testosterone

!  Testosterone implants have shown less s7mula7on of breast 7ssue

!  Treatment with testosterone and estradiol implants does not increase the risk of breast cancer, even in breast cancer survivors

HRT & Breasts take home: TRT protects! HRT & The Bones

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Androgen Receptors in Bone cells

•  Androgen receptors are found in all three bone cells: osteoclasts, osteoblasts and osteocytes.

•  There is an abundance of both AR and estrogen receptors in osteoblasts, indica7ng the dual role of T and E2 in normal bone physiology.

•  Androgens may also regulate osteoblast ac7vity via a more rapid mechanism through receptors on the osteoblast surface.

Androgens, Muscle and Exercise

•  Muscle exerts a greater load on bone than does weight-‐dependent gravity.

•  This mechanical s7mula7on induces the ac7va7on of bone forming sites on periosteal bone surfaces.

•  Mechanical loading when combined with estrogen, results in a greater osteogenic response than either separately.

•  This is probably the result of estrogens an@resorp@ve quality and of the s@mula@on of bone forma@on with exercise.

•  Approximately 4% of muscle mass is lost during the first 3 years a_er menopause.

•  Postmenopausal androgen therapy increases lean 7ssue mass and decreases fat mass.

1.  Testosterone: “Bone Builder”

2.  Demonstrated Four-‐fold Increase in Bone Density vs. Oral Estrogen and 2.5x Greater than Patches

•  8.3% per/year for Pellet Therapy •  3.5% per/year for Patches •  1-‐2% per/year for Oral Estrogen

Studd, J WW, et al (1990) Am Journal OB/GYN 163, 1474-‐1479

Oral Patch Pellets Control

-2

0

6

8

10

Cha

nge

in b

one

dens

ity (%

) Vertebral Femoral neck

4

2

Bone Density Increases with Different HRT

Christiansen et al, 1981; Lindsay et al, 1976; Stevenson et al, 1990; Studd et al, 1990.

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Morris Notelovitz et al Obstetrics & Gynecology, Volume 70, No. 5, Nov 1987 Metabolic & Hormonal Effects of 25mg & 50mg, 17-‐B-‐Estadiol Implants

•  Two year study demonstrated marked increase in bone density.

•  No adverse effects were noted in the coagula7on inhibi7on and fibroinolysis assays in the pellet pa7ents.

•  Systolic and diastolic blood pressure unaffected.

Estradiol Pellet implant study How about Ca++? •  Meta-‐ analysis of 29 studies showed non-‐significant reduc7on in the risk for fracture

•  Vitamin D plus calcium reduced the risk of fracture

•  Vitamin D alone reduced risk of fracture by 16%

JAMA 2013; 1-8

Bisphosphonates

!  Slow the natural resorp7on and remodeling process, making bones super hard

!  Cell and bone mineral deple7on are actually accelerated if you are using bisphosphonates and minerals are not being adequately replaced

!  There are cases of jaw bone necrosis has caused the teeth to fall out

!  Increased risk of a fib lead leading to blood clots

HRT & The Brain

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Alzheimer’s Disease •  Number of Alzheimer’s cases will triple by 2050 •  Cost will increase 500% to 1.1 trillion dollars •  Alzheimer’s pa7ents spend 3x more on health care cost than other pa7ents

•  Several Trials are under way to try and prevent the disease (SERM, SARMS)

•  What if the answer already there?

Neurology 2/2013 Journal of Alzheimer’s and Dementia 2/2013

•  Both Estrogen and Testosterone have Neuroprotec7ve role •  Women have a higher incidence of AD 8:1 over men •  Women with lower E2 levels have even greater risk of AD •  There is overwhelming evidence that E and T helps decrease apoptosis

•  This protec7ve effect of both hormones decreases the beta amyloid deposi7on

Pike,CJ:Frontiers in Neuroendocrin 30(2009):239 Proc Natl

Acad Sci USA. 2000 Feb 1;97(3):1202-5.

HRT & The Brain

Alzheimer’s Disease Alzheimer's Disease- Cache County Utah Study

•  1800 patients •  30% reduction if HRT started within 5 years of

menopause and especially if used for more than 10 years.

Neurology 2012 October 30;79:1846-52.

Key: PREVENTION AND EARLY TREATMENT

Testosterone and Parkinson’s Dz – Improves the Non-‐ Motor Symptoms

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HRT & The Heart Testosterone and C.A.D. Quick Facts •  Testosterone reduces insulin resistance

•  Testosterone reduces cholesterol

•  Testosterone reduces visceral fat

•  Testosterone reduces C.A.D.

European J Endocrinology 2006;154:899-906

•  Aroma7ze-‐able testosterone demonstrated an7-‐anginal effects in humans

•  High serum testosterone is associated with reduced risk of cardiovascular events in elderly men

Hamm, L., J. Clin Endo. 1942;2:325-328 Lesser, M.A., J. Clin. Endo. 1946;6:549-557

Wu S.Z., Weng X.Z., Chin Med Sci. 1993;106:415-418

J Am Coll Cardiol. 2011 Oct 11;58(16):1674-81.

Testosterone and C.A.D.

•  Researchers followed more than 3,600 elderly men living on their own for about five years on average.

•  Over that @me, about six percent died due to heart disease, with men who had low levels of free testosterone leading the pack.

Journal of Clinical Endocrinology & Metabolism, October

19, 2011.

Endogenous Testosterone and Mortality Due to All Causes, Cardiovascular Disease, and Cancer in Men

•  11,606 men aged 40 to 79 years •  Endogenous testosterone concentra7ons at baseline were inversely related to mortality due to all causes , cardiovascular disease, and cancer

•  41% increase in all cause mortality •  Low T is not only protec7ve but predic7ve of CV disease

Circulation. 2007; 116: 2694-2701

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Associa&on of Endogenous Sex Hormones and Coronary Calcifica&on in Pa&ents with no History of Coronary Heart

Disease

•  3164 men •  No known C.A.D. •  U.C.L.A. and Johns Hopkins •  Low endogenous sex hormones and high sex hormone binding globulin are correlated with increased CACS ( coronary artery and calcium score), a_er adjustment for age and CHD risk factors

Khazai B.,Circulation. 2012; 126: A13802

Testosterone and Myocardial Effects

•  Aroma7ze-‐able testosterone demonstrated an7anginal effects in humans

•  High serum testosterone is associated with reduced risk of cardiovascular events in elderly men

Hamm, L., J. Clin Endo. 1942;2:325-328 Lesser, M.A., J. Clin. Endo. 1946;6:549-557

Wu S.Z., Weng X.Z., Chin Med Sci. 1993;106:415-418 J Am Coll Cardiol. 2011 Oct 11;58(16):1674-81.

Estradiol and CV Disease in Men “Its not just Low T”

•  501 men with chronic heart failure •  Men in the lowest estradiol quin7le were 217% more likely to die during a 3-‐year follow-‐up

•  Men in the highest estradiol quin7le were 133% more likely to die

•  Men in the balanced quin7le—had the fewest deaths •  Excess estrogen contributes to the development of atherosclerosis

•  Men with Low T and Low E 96% increase overall mortality

JAMA. 2009 May 13;301(18):1892-901 J Clin Endocrinol Metab. 2009 Jul;94(7):2482-8

Metabolic Effects of Testosterone

•  Inverse rela7onship between endogenous testosterone levels and plasma insulin levels

•  Healthy men with low total testosterone have increased insulin levels, increased FBS and 2HR P.P. glucose, triglycerides total and LDL cholesterol, Apo A-‐1 Lipo P.

Simon D., et al. Telecom Study. J. Clin. Endo. Metab. 1997; 821: 682-685

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Testosterone and Metabolic Syndrome

Low testosterone is associated with excess abdominal fat, loss of insulin sensi@vity, and atherosclerosis.

Clin Endocrinol Metab. 2002 Oct;87(10):4522-7 J Clin Endocrinol Metab. 2008 May;93(5):1834-40

J Androl. 2009 Jan-Feb;30(1):23-32

the Rotterdam study. J Clin Endocrinol Metab. 2002 Aug;87(8):3632-9

1 in 7 Premenopausal Women Die…

HEART DISEASE

For Postmenopausal Women that Number

RISES to 1 in 3!

More Fatal Than Any Other Disease in women

•  Heart disease is the leading cause of death of American women, killing more than a third of them.

•  More than 200,000 women die each year from heart axacks, five 7mes as many women as breast cancer.

•  35.3% of deaths in American women over the age of 20, or more than 432,000, are caused by cardiovascular disease each year.

•  More than 159,000 women die each year from conges7ve heart failure, accoun7ng for 56.3% of all heart failure deaths.

Susan Davis, et al Menopause Volume 7, No. 6, pp.395-‐401

Estrogen replacement with pellets has effects on body fat in post menopausal women that are associated with improved lipid parameters.

–  decreased total Cholesterol & LDL, –  Increased HDL, –  decreased triglycerides.

Addi7on of testosterone does not negate the favorable effects of estrogen on LDL Cholesterol. Marked reduc7on in fat mass was seen in the estrogen plus testosterone group a_er two years.

HRT and Cholesterol in Women

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CLINICAL STUDY Endogenous sex hormone levels in postmenopausal women

undergoing carotid artery endarterectomy

•  The study provides evidence of a positive association between low serum androgen levels and severe ICA (internal carotid artery) atherosclerosis in postmenopausal women.

•  It suggests that higher, but physiological levels of androgens in postmenopausal women have a protective role in the development of atherosclerosis of ICA.

European Journal of Endocrinology 156 687–693

HRT & The Joints

!  10% of men and 18% of women >60 Y.O. have osteoarthri7s

!  By 2020 OA will be 4th leading cause of disability

!  Chondrogenic Progenitor Cells are present in arthri7c 7ssue

!  Both Estrogen and Testosterone can s7mulate these cells

Arthri7s: Hormones Could Ease Pain

Arthri7s and Rheuma7sm, April 2010

Hormone replacement therapy and mid-‐term implant survival following knee or hip arthroplasty for osteoarthri7s: a popula7on-‐based cohort study

•  Osteolysis and subsequent prosthesis loosening is the most common cause for revision following total knee arthroplasty (TKA) or total hip arthroplasty (THA).

•  1986 to 2006 …2700 pa7ents •  HRT use is associated with an almost 40% reduc@on in revision rates amer a TKA/THA

Annals of the Rheumatic Diseases 1/2014

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For hormone balance to be OPTIMAL, you MUST treat deficiencies of:

" Vitamins A, D and K " Iodine

" Thyroid optimization

Vitamin D3: The OTHER powerful Hormone

•  Low (Levels under 60ng/dl) Vitamin D3 levels have been implicated in many different kinds of cancer ranging from colon, breast, prostate, and colorectal, to lung, ovarian, esophageal, kidney and bladder cancer.

•  July 2008 American Journal of Clinical Nutrition - Fred

Hutchinson Cancer Research Center in Seattle report a high incidence of Vitamin D deficiency among female breast cancer survivors.

•  Vitamin D3 Plays role in optimal Cardiac functioning:

Framingham Heart Study - people with Vitamin D levels below 15 ng/ml were twice as likely to experience a heart attack, stroke or other cardiovascular event. Other studies show D levels under 60 hold 160% increase risk of CAD

Vitamin D3: How much to supplement with? LAB “NORMAL” VS OPTIMAL?

•  Under summer condi7ons it is frequently possible to generate

about 20,000 units of vitamin D by exposing your skin to the sun for merely 20 minutes!

•  Currently, the U.S. RDA for vitamin D is 400 IU for the majority of the popula7on to prevent rickets (eradicated in US but STILL RDA)

•  To achieve the healthy blood levels, adults need a MINIMUM of 5000 IU of D3 daily and up to 10,000 IU daily –  Interes7ngly, the majority of that are taking vitamin D are taking 1,000

units, and they believe they are taking “high” dose

Testosterone and Vitamin D •  Deficiencies of EITHER free testosterone or 25-‐hydroxyvitaimin D resulted in a 40% increased risk for all-‐cause mortality (p=0.002)

•  Deficiencies of free testosterone AND 25-‐hydroxyvitaimin D resulted in a 111% increased risk for all-‐cause mortality (p<0.001)

•  Deficiencies of free testosterone AND 25-‐hydroxyvitamin D resulted in a 77% increased risk for cardiovascular mortality (p<0.001)

•  Deficiencies of EITHER free testosterone or 25-‐hydroxyvitaimin D resulted in a 60% increased risk for non-‐cardiovascular mortality (p=0.011)

•  Deficiencies of free testosterone AND 25-‐hydroxyvitaimin D resulted in a 133% increased risk for non-‐cardiovascular mortality (p<0.001).

Clin Endocrinology (Oxf). 2012 Feb 22

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Type II Hypothyroidism !  The thyroid gland produces “normal” amounts of

hormone, but the cells are unable to utilize the hormone properly

!  Some experts call this thyroid hormone resistance (which may be regarded as similar to insulin resistance, or Type II Diabetes)

!  In the 1930’s this phenomenon was being described in the literature as Incipient Hypothyroidism

!  Dr. Crile stated “..it is not a life or death condition, however the well-being of many people could be improved if this condition were more detected and treated in its early stages”

!  Like Type II DM, it is a receptor issue !  Environmental Toxins and low iodine

exacerbate the Issue

Symptoms of Type 2 Hypothyroidism/resistance •  Hair loss, brixle nails, dry skin, migraines, immune suppression, asthma and allergies, heart arrhythmias, anxiety, depression, FATIGUE, stubborn weight gain, menstrual problems and infer7lity are all common symptoms of thyroid insufficiency.

•  GENERAL OVERALL DECREASED SENSE OF WELL-‐BEING

Anxiety, depression, nervousness, irritability

are NOT Prozac deficiency states!

Type II Hypothyroidism New Thyroid Concepts

•  T3 is needed for fat loss •  T3 protects against arrhythmias and heart disease

•  T3 decreases with stress or die7ng •  T4 does not necessarily convert to adequate T3

•  Increased risk for anemia and other immunological changes in Hypothyroidism

•  Reverse T3 reverses T3

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Thyroid Lab tests -‐ Op&mal

•  Free T3 in upper 1/3 of reference range – 3.5-‐4.2 ng/dl

•  T4 is a pro hormone-‐ not ac7ve •  TSH < 1.5 reflec7ve of T4 •  T.P.O. over 34 or pa7ent has Hashimoto’s Thyroidi7s

•  How to treat?

How do I treat? •  Desiccated Thyroid: Armour vs. Compounded vs. Natur-‐throid •  Iodine/Iodide combo (Iodorol) 12.5-‐25 mg daily •  Gluten free diet and Selenium for Hashimotos

Rule of thumb/place to start: TSH: Desiccated Thyroid: 1.5-2.0: 1 grain 2.1-5.0: 1.5 grain >5.0 2 grains Increase/Titrate slowly to symptom relief (1/2 grain q 2-4 weeks) Natur-throid more efficacious and less side effects than Armour

Goal is SYMPTOM RELIEF Not LAB relief… but Free T3 in upper range FEELS the best!

Iodine •  Necessary for proper immune func7on •  Concentrated in thyroid, breast, ovary and prostate •  Iodine deficiency increases the risk of breast, prostate, endometrial and ovarian cancer

•  Iodine increases 2 oh-‐estrone (good estrogen) •  Halides o_en displace Iodine, reducing thyroid func7on (chloride, fluoride, bromide)

•  Very potent an7oxidant

Iodine and Hypothyroidism

Clin Endocrinol (Oxf). 2011 May;74(5):631-5

9/5/15


18 year old male with Low T?

Key take-‐homes

•  Hormone imbalance can occur in men and women

at any age •  Not all therapies are created equal •  HRT done right IS Evidence Based Medicine •  Hormone balance is not a “one size fits all

approach” •  Low normal labs may not be optimal for health

Vitamin D, iodine, thyroid, testosterone, etc.

Your pa&ents want to LIVE

not just be alive

Questions?

9/5/15


Recommended Resources

•  Type 2 Hypothyroidism: Dr. Mark Starr •  Iodine: Why you need it, why you cant live without it: •  Salt Your Way to Health Dr. David Browns@en •  Breast Cancer and Iodine: Dr. David Derry •  The Iodine Crisis: Lynne Farrow •  The Calcium Lie, What your doctor DOESN’T know could kill

you: Dr. Robert Thompson •  Vitamin K2 and the Calcium Paradox: Dr. Kate Rheaume-‐Bleue •  Overdosed America: Dr. John Abramson

hormone havoc: terri%suresh%aprn,%msn,%dnps

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